Palliative Care Case Study and Discussionwordpress.uchospitals.edu/colemanfellows/files/2013/02/Case-Stdy... · Palliative Care Case Study and Discussion Anna Lee Hisey Pierson, M.

Palliative Care

Case Study and Discussion

Anna Lee Hisey Pierson, M. Div., BCC-HPCC

Judy Burke, L.C.S.W.

September 18, 2015

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Disclosure

There are no relevant conflicts of interest to

disclose for presenters associated with this

presentation.

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HIPAA

• Information in this case study is not to be shared

outside learning environment.

• Patient/family information has been altered to

protect their identify.

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Objectives

1. Describe impact of informed consent on patient

outcomes

2. Explain the importance of honoring Advance

Directives

3. Demonstrate influence of multicultural

background of health care providers and the

care perspective

4. Explain how an interdisciplinary Palliative Care

Team utilizing a transdisciplinary approach

impacts patient outcomes

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Transdisciplinary Team Approach

“A transdisciplinary team allows members to

contribute their own knowledge and expertise, but

efforts are collective in determining best ideas or

approaches, according to the North Central

Regional Educational Laboratory overview of the

topic. When transdisciplinary teams are used in

health care, providers from multiple disciplines

collaborate and share ideas from the beginning to

create a total health care plan that covers all

necessary diagnoses and treatment for a patient.” Neil Kokemuller, Demand Media, www.smallbusiness.chron.com ,

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Presenters

• Judith Burke, LCSW

• Married Middle aged

• Caucasian Protestant faith

• Master’s Trained Licensed Clinical Social Worker

• Completed fellowship in advanced psychoanalytic theory and practice

• Anna Lee Hisey Pierson, MDiv, BCC-HPCC

• Married Protestant faith

• Middle aged Parent

• Caucasian Master’s Trained

• Board Certified Hospice and Palliative Chaplain

• Background in nursing and social work

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Hospital Culture

• Level I Trauma Center

• Community, non-academic hospital

• Licensed for 333 beds

• Heterogeneous physicians

• Homogenous clinical staff

• Located in a wealthy suburban county in Illinois

• Interdisciplinary Palliative Care Team (Palliative certified or in process=Physician, Nurses, Social Worker, Chaplain)

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Case Study • Patient Demographics

• Age Mid 80+ female Caucasian

• Lutheran Divorced

• Three children Independent

• Retired Academic Middle Class

• Grandparent, great grandparent

• Activities

• Family Lunch with friends

• Cards Church involvement

• Dancing

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Medical History

•Chronic Atrial Fibrillation

•C-Diff

•Hypertension

•Hyperlipidemia

•1954 Hysterectomy

•1970 Lumpectomy bilateral breast

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Chronology of Events

Day 1 – Emergency Room – Ambulance admit

Unresponsive to verbal commands, not in acute distress

-CT head-acute appearing infarct viewed

-MRI-very large cerebral infarct

-MRA-showed occlusion of left middle cerebral artery

Day 2 – Inpatient Admission Telemetry

Chest x-ray-cardiomegaly with large pleural effusion bilaterally

NG-feeding placed

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Events continued

Day 3 – Code status- No Intubation/No CPR

Day 4 – Rapid Response Team(RRT)-Rapid

VR and high BP- Family at bedside

Ist Ethical Dilemma

Palliative Care Triggered consult-

await CCU bed

Poor prognosis documented

Day 5 – RRT-Hypoxia, 70% O2, copius

secretions

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Events continued

Day 6 –CCU

Health Care Power of Attorney provided by

family, naming daughter as agent

Day 7 – Family refusing Palliative Care Consult

Patient opened eyes for first time

Day 8 – Palliative Care Goals of Care phone

conference

Day 9 - Restraints placed

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Events continued

Day 10 –Follows no commands

Day 11 – Palliative Care Meeting Scheduled

New Cardizem Drip-Atrial Fibrillation

Day 12 – Family requested DNR, hospice

Day 13 – Hospice meet with family

Attending physician reports improvement

and denies hospice

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Events Continued

Day 13 – Pneumonia diagnosis

Day 15 – Ethics Consult

Hospice reconsulted per daughter request

Peg tube placement on hold-atrial Fibrillation

Day 16 – Hospice evaluation

Cancelled Peg Insertion

POLST-Full DNR, comfort

Attending physician agreed with hospice

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Events Continues

Day 17 – Transferred to Skilled Nursing Care

Facility on Hospice

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Palliative Care

“Palliative care is an approach that improves the

quality of life of patients and their families facing

the problem associated with life-threatening

illness, through the prevention and relief of

suffering by means of early identification and

impeccable assessment and treatment of pain and

other problems, physical, psychosocial and

spiritual.”

http://www.who.int/cancer/palliative/definition/en/

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Palliative Care

•”Provides relief from pain and other distressing

symptoms;

• Affirms life and regards dying as a normal

process;

• Intends neither to hasten or postpone death;

• Integrates the psychological and spiritual aspects

of patient care;

• Offers a support system to help patients live as

actively as possible until death;” http://www.who.int/cancer/palliative/definition/en/

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Palliative Care

• “uses a team approach to address the needs of patients

and their families, including bereavement counselling, if

indicated;

• will enhance quality of life, and may also positively

influence the course of illness;

• is applicable early in the course of illness, in conjunction

with other therapies that are intended to prolong life, such

as chemotherapy or radiation therapy, and includes those

investigations needed to better understand and manage

distressing clinical complications.”

• http://www.who.int/cancer/palliative/definition/en/

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Domains of Palliative Care

Domain 1: Structure and Processes of Care

Domain 2: Physical Aspects of Care

Domain 3: Psychological and Psychiatric Aspects

of Care

Domain 4: Social Aspects of Care

Domain 5: Spiritual, Religious and Existential

Aspects of Care

Domain 6: Cultural Aspects of Care

Domain 7: Care of the Imminently Dying Patient

Domain 8: Ethical and Legal Aspects of Care www.qualityforum.org/Projects/Palliative_Care_and_End-of-Life_Care...

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Psycho-Social

• Obtaining information from the patient regarding who the patient perceives to be their most important support person(s)

• Identify the primary caregiver(s)

• Discuss Advanced Care Planning with patient, family, friend(s), and/or caregiver(s)

• Explain to patient/family/caregiver(s) what services and resources can be provided by the palliative team

• Conduct a needs assessment, including social, psychological, spiritual, cultural, financial, vocational, and practical aspects of functioning

• Link patient and family to needed community resources, i.e.: public assistance, food pantries, clothing and utilities assistance etc…

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Spirituality

Spirituality refers to the way we seek and express ultimate meaning and purpose in our lives. It is also the way we experience our connectedness to others, to nature, and to God or the sacred.

Christina Puchalski, M.D., M.S., F.A.P.C.,1 Betty Ferrell, Ph.D., M.A., F.A.A.N., F.P.C.N.,2

Rose Virani, R.N.C., M.H.A., O.C.N., F.P.C.N.,2 Shirley Otis-Green, M.S.W., L.C.S.W., A.C.S.W., O.S.W.-C.,2

Pamela Baird, A.A., al, “Improving the Quality of Spiritual Care as a Dimension of Palliative Care: The Report of the Consensus Conference”, Journal of Palliative Care, Vol. 12, Number 10, 2009

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Psycho-Social /Spiritual Identifiers

Needs Interventions Outcomes

Conflicted Belief System

Complicated grief with

death of estranged

brother

Expressed importance of

prayer, scripture and

music

Discussed faith tradition

and God’s Plan

Explored impact of

Physicians beliefs on

informed consent

Explored integration of

sense of guilt and loss of

brother

Validated sense of

sadness of mother’s loss

functionality

Explored source of

strength

Provided scripture,

prayer, music

Family discussing plan of

care together though

varied beliefs

Glimpse of grief and

dialogue of impending

loss

Comforted through

sharing prayer, scripture

and music

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Psycho-Social /Spiritual Identifiers Needs Interventions Outcomes

Existential Concerns

Anger at Physicians

Explore understanding of

Suffering

Discuss God’s Plan

Diffused anger

Explored sense of health

realities

Reduced feeling of

God’s punishment

Restored belief in God

Reduced shock of

altered functioning

Coping realistically with

prognosis

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Psycho-Social /Spiritual Identifiers Needs Interventions Outcomes

Physician/associate

cultural/religious

Influences

Lack of informed consent

Explored

physician/associate

belief system

Facilitated Ethics

Consult

Supported

nursing/management

associates

Explored meaning of

patient’s Advance

Directive wishes

Educated on role of

agent

Facilitated Ethics

Consult

Facilitated consensus of

medically indicated

prognosis

Physician communicated

informed consent

Congruent medical

information provided by

all physicians and

associates

Associate moral distress

reduced

Agent able to act on

patient’s Advance

Directives wishes

Desired quality of life

respected

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Impact of Transdisciplinary

Palliative Care Team • Interdisciplinary trained Palliative Care Professionals

• Daily Morning Huddle

• Palliative program longevity and continuity of staff

• Transdisciplinary engagement-patient/family interventions

• Recognition of Palliative Care as integral aspect of patient

care

• Ethical awareness and integration of cultural/religious

diversity

• Comprehensive, trust-filled, valued interdisciplinary team

of experts challenging one another and continuing to learn

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Conclusion

• Aligned patient’s plan of care with values

• Agent followed patient’s Advance Directives

• Physicians provided informed consent

• Physicians supported medically indicated plan of

care

• Supported faith and values

• Moral Distress of associates resolved

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Questions

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Thank You

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[email protected]

630-275-1189

[email protected]

630-275-6969

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[email protected]

630-275-1189

[email protected]

630-275-6969

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